Blood Flow Restriction Training in ACL Rehab

It's not if, It's when!

Blood Flow Restriction Training in ACL Rehab – It’s not if, It’s when!

“You should begin high-quality rehabilitation immediately after an ACL injury”, as earlier stated in a blog post. Everyone with an ACL injury experiences early loss in muscle mass and muscle strength. So the first phase is crucial! 

Can we reduce these losses and restore them more early with Blood Flow Restriction Training (BFRT)?

Credits to The BFR Pros

Yes you heard that right! Blood Flow Restriction Training is able to increase muscle mass and strength with much lesser weights or NO weights at all. Which is absolutely important to maintain and improve post ACL reconstruction to restore daily functioning and participation to sports!


(Practice guideline Kotsifaki et al., 2023)

Based on the scientific evidence, high intensity strength training is necessary to get these improvements. But all of you know that training with heavy loads is far from possible after that ACL reconstruction. We need to protect tissue healing and respect the reduced load capacity of the knee! Especially when there are weight bearing restrictions given by the surgeon because of for example a meniscal repair.

So we have no other choice than applying low intensity training. But almost always muscles aren’t getting into fatigue and thus you aren’t experiencing the feeling of the pump, because of the very high amount of repetitions needed. The pump is actually very important to achieve because we then know that mechanisms are taking place and we are reducing the loss or even gaining muscle mass and strength.


Besides that, BFR could:

  • Reduce pain
  • Reduce loss in bone mineral density and bone mass
  • Possibly reduce swelling
  • Possibly resolve activation problems
  • Maintain or improve aerobic capacity, muscle mass and muscle strength with Aerobic BFRT
  • Improve physical functioning and quality of life
  • Be used safe in adolescents


How should BFRT be applicated?

Step 1: is there an indication?

Who is likely an appropriate BFR training candidate? The evidence strongly supports BFR’s use in those patients with either a loading problem or a pain problem.

BFR blog

After ACLR:

  • Load capacity is suppressed
  • Pain is a major factor influencing the knee function

No discussion that there is an indication!

Step 2: is it safe?

  • The evidence does not support the assertion that BFR creates blood clots! It seems to reduce the possibility of a blood clot
  • BFR is safe if the following requirements are met:
    • Medical screening passed
        • Rule out absolute contra-indications
        • Take into account relative contra-indications
        • Blood pressure assessment
        • Consult with doctor or expert (when in doubt)
    •  Applied by an experienced and trained therapist
    • Correct protocols and techniques applied
    • Use of objective LOP (limb occlusion pressure) assessment and pneumatic cuffs or validated automatic devices

Choose your cuffs wisely!

BFR Training acl


Step 3: write a BFR training program!

  • Take into account medical screening and patient characteristics
  • Determine your training pressure based on a LOP assessment
  • Take into account the pressure/load continuum
  • Implement strategies to reduce perceptual demands to maintain long-term compliance
  • Think about The Pillars of BFR Training throughout your training and within each session. Use them as a progressive framework/ continuum to applying BFRT from very easy to harder and select the right exercises.
pillars of BFR

Pillar 1: cell swelling/ passive BFR

  • Goals of Pillar 1:
    • Short familiarization period
    • Reduction in atrophy and muscle strength loss

Pillar 2: cardiovascular training

  • Goals of Pillar 2:
    • Increase in muscle mass and strength
    • Maintenance or improvement of aerobic capacity
    • Pain relief
    • Bridge towards pillar 3

Pillar 3: resistance training

  • Goals of Pillar 3:
    • Pursue the same benefits as with traditional high load strength training without all the external mechanical stress
    • Attenuate atrophy
    • Increase muscle hypertrophy
    • Increase muscle strength and endurance
    • Resolve activation problems
    • Pain relief
    • Facilitate bone metabolism

Pillar 4: performance training

Not often used in ACL rehab

Individuals can skip pillar 1 and/or 2 if your evaluation suggests that they are able to tolerate the stress of later pillars.


BFRT is already being used all over the world to accelerate fatigue and rehab. Not only with elite athletes, but also with the recreational athlete and non-sporter after ACL ruptures. Doctors and surgeons are already referring to the use of BFR in their patients rehab! Don’t stay behind. It’s not IF, it’s WHEN!

Are you a doctor or a patient and do you want to find a BFR certified physio? Look at:


Authors: Mathias Thoelen 

Mathias thoelen profile photo

Mathias Thoelen

Mathias Thoelen is a Belgian Sports Physical Therapist working at Sports Medical Center Anna TopSupport Eindhoven in The Netherlands. Mathias currently teaches BFR Workshops in Europe for the BFR Pros. His ambition is to make Blood Flow Restriction Training great in Europe and beyond by providing evidence-based workshops about the safe and objective application of BFRT in different populations. In addition, he is engaged in research on training with BFR in post operative patients.

“The lack of knowledge and experience is a major problem as the demand for BFR is increasing worldwide.
My goal is to provide a safe, objective and evidence-based worldwide application of BFRT!”

If you have any questions, Mathias Thoelen and The BFR Pros are ready for you!

bfr pros logo


THE BFR PROS are a team of clinicians, coaches and athletes who have combined forces to bring you the real science and tools behind Blood Flow Restriction.


  • Abe, T., Kearns, C. F., & Sato, Y. (2006). Muscle size and strength are increased following walk training with restricted venous blood flow from the leg muscle, Kaatsu-walk training. Journal of applied physiology, 100(5), 1460-1466.


  • Abe, T., Fujita, S., Nakajima, T., Sakamaki, M., Ozaki, H., Ogasawara, R., … & Ishii, N. (2010). Effects of low-intensity cycle training with restricted leg blood flow on thigh muscle volume and VO2max in young men. Journal of sports science & medicine, 9(3), 452.


  • Bond, C. W., Hackney, K. J., Brown, S. L., & Noonan, B. C. (2019). Blood flow restriction resistance exercise as a rehabilitation modality following orthopaedic surgery: a review of venous thromboembolism risk. journal of orthopaedic & sports physical therapy, 49(1), 17-27.


  • Formiga, M. F., Fay, R., Hutchinson, S., Locandro, N., Ceballos, A., Lesh, A., … & Cahalin, L. P. (2020). EFFECT OF AEROBIC EXERCISE TRAINING WITH AND WITHOUT BLOOD FLOW RESTRICTION ON AEROBIC CAPACITY IN HEALTHY YOUNG ADULTS: A SYSTEMATIC REVIEW WITH META-ANALYSIS. International Journal of Sports Physical Therapy, 15(2).


  • Hughes, L., Grant, I., & Patterson, S. D. (2021). Aerobic exercise with blood flow restriction causes local and systemic hypoalgesia and increases circulating opioid and endocannabinoid levels. Journal of Applied Physiology, 131(5), 1460-1468.


  • Hughes, L., Paton, B., Haddad, F., Rosenblatt, B., Gissane, C., & Patterson, S. D. (2018). Comparison of the acute perceptual and blood pressure response to heavy load and light load blood flow restriction resistance exercise in anterior cruciate ligament reconstruction patients and non-injured populations. Physical Therapy in Sport, 33, 54-61.


  • Hughes, L., Patterson, S. D., Haddad, F., Rosenblatt, B., Gissane, C., McCarthy, D., … & Paton, B. (2019a). Examination of the comfort and pain experienced with blood flow restriction training during post-surgery rehabilitation of anterior cruciate ligament reconstruction patients: A UK National Health Service trial. Physical Therapy in Sport, 39, 90-98.


  • Hughes, L., Rosenblatt, B., Haddad, F., Gissane, C., McCarthy, D., Clarke, T., … & Patterson, S. D. (2019b). Comparing the effectiveness of blood flow restriction and traditional heavy load resistance training in the post-surgery rehabilitation of anterior cruciate ligament reconstruction patients: a UK National Health Service Randomised Controlled Trial. Sports Medicine, 49(11), 1787-1805.


  • Hughes, L., Rosenblatt, B., Paton, B., & Patterson, S. D. (2018). Blood flow restriction training in rehabilitation following anterior cruciate ligament reconstructive surgery: A review. Techniques in Orthopaedics, 33(2), 106-113.


  • Jack, R. A., Lambert, B. S., Hedt, C. A., Delgado, D., Goble, H., & McCulloch, P. C. (2022). Blood Flow Restriction Therapy Preserves Lower Extremity Bone and Muscle Mass After ACL Reconstruction. Sports Health, 19417381221101006.


  • Kotsifaki, R., Korakakis, V., King, E., Barbosa, O., Maree, D., Pantouveris, M., … & Whiteley, R. (2023). Aspetar clinical practice guideline on rehabilitation after anterior cruciate ligament reconstruction. British Journal of Sports Medicine, 57(9), 500-514


  • Patterson, S. D., Hughes, L., Warmington, S., Burr, J., Scott, B. R., Owens, J., … & Loenneke, J. (2019). Blood flow restriction exercise: considerations of methodology, application, and safety. Frontiers in physiology, 10, 533.


  • Prue, J., Roman, D. P., Giampetruzzi, N. G., Fredericks, A., Lolic, A., Crepeau, A., … & Weaver, A. P. (2022). Side effects and patient tolerance with the use of blood flow restriction training after ACL reconstruction in adolescents: a pilot study. International Journal of Sports Physical Therapy, 17(3), 347.


  • Rolnick, N., Kimbrell, K., Cerqueira, M. S., Weatherford, B., & Brandner, C. (2021). Perceived Barriers to Blood Flow Restriction Training. Frontiers in Rehabilitation Sciences, 14.


  • Wernbom, M., & Aagaard, P. (2020). Muscle fibre activation and fatigue with low‐load blood flow restricted resistance exercise—An integrative physiology review. Acta Physiologica, 228(1), e13302.